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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT S <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address r1 City Lot Size PM ` <br /> Owner's Nam �� _T <br /> Address �` �/ Phone <br /> Contractor Address <br /> License No. Phone_ <br /> TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ sti SYSTEM REPAIR © OTHER ❑ q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES', � DISPOSAL FLD. PROP. LINE <br /> j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED IUSE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial <br /> LJ Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private C Gravel Pack ❑ Tracy Type of Casing Specifications <br /> {� Public ED Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation —,Approx. Depth l I Eastern"""-- , .Surface Seal-Installed-by--- - <br /> t # State Work Done <br /> Repair Work Done ❑ Type of Pump H P. <br /> Well Destruction" C1 Well Diameter Sealing Material (top 50'1 �. <br /> Depth Filler Maferial-(Below 50') — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIR/ADDITION~{.•]...,..DESTRUCTION (No septic system permitted it public sewer is <br /> a vailable within 200 feet.) <br /> t Installation will'serve: Residence L Commercial Other <br /> Number of living units: Number of bedrooms V <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 'e Capacity No. Compartments <br /> s Method of Disposal <br /> PKG. TREATMENT PLT. ❑ �, a <br /> • Distance to nearest:# Well Foundation Property Line <br /> 1 i <br /> LEACHING LINE ❑ No. & Length of lines. Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` \' <br /> — a <br /> SEEPAGE PITS i I Depth ' Size Number <br /> SUMPS Ll Distance to nearest:' y" Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ) 1. <br /> \�'\ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and fit, <br /> rules and regulations of the San Joaquin Local Health District. f <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued., I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ` <br /> The applicant st ca for all quire s io �mpl.te.,d,,,awing on reverse side. <br /> h ' +�. ! Date: <br /> Sig Title: <br /> FOR DEPARTMENT USE ONLY <br /> A ea <br /> Z <br /> Application Accepted by Date 1 <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + INFO <br /> ♦.EH 13.24IREV.1/x5) ?5, 6 <br /> EH 14-2a <br />